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2014 enrollment form - tennessee state university

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IMPORTANT • I understand that this is not an application for insurance. To enroll or change my medical or dental insurance, I must complete the proper insurance forms. • I hereby authorize my employer to reduce my gross salary before federal, state and social security taxes are calculated by the total amount of annual salary reduction indicated above. • I understand the contribution to my Social Security account will be reduced, since contributions will be based on my income after reduction. • I understand that any amount remaining in any Flexible Spending Account that is not used during the plan year will be forfeited since it cannot be carried forward to the next plan year. • I understand that the funds in one FSA account cannot be used to reimburse expenses covered by another account. • I understand that expenses for which I am reimbursed cannot be deducted on my income tax returns. • I understand that the funds in the FSA account can only be paid out to reimburse payment of eligible expenses actually incurred during the plan year. • I understand that the amount of salary deduction will include the items specified above and will continue in effect unless I terminate employment or file an approved change in status, within 90 days of a qualifying event. • I understand and agree that my employer and Fringe Benefits Management Company, a Division of WageWorks, will not incur any liability resulting from either my participation in or my failure to sign or accurately complete this Enrollment Form. I further understand that if I elect not to participate in salary reduction with respect to the benefits listed above, I hereby forego my right to participate during the upcoming plan year, unless otherwise provided by law. • I understand that I may be asked by the IRS to provide the FEI number of my daycare provider. • I certify that: 1) I will only use my FSA to pay for IRS-qualified expenses and only for my IRS-eligible dependents, 2) I will exhaust all other sources of reimbursement, including those provided under my Employer’s plans before seeking reimbursement from my FSA, 3) I will not seek reimbursement through any other source, and 4) I will collect and maintain sufficient documentation to validate the foregoing. Flexible Spending Accounts Complete the worksheets provided in your Reference Guide before deciding on the amount(s) to be entered in the sections below. If you have questions, consult your Reference Guide, or call Customer Care at 1-800-342-8017. You may also contact Customer Care at www.myFBMC.com. In Box #1, indicate the total dollar amount you elect to contribute for the Plan Year. In Box #2, indicate the number of regular payroll checks you expect to receive during the Plan Year (consult your payroll office if you are unsure of how many checks you will receive). In Box #3, indicate the reduction amount per pay period. ( ) Customer Care 1-800-342-8017 7 a.m.-10 p.m. 12 26 24 WORK PHONE HOME PHONE HOME ADDRESS [STREET] CITY STATE ZIP LAST NAME FIRST NAME M SOCIAL SECURITY NUMBER PAY CHECK EFF. DATE: (FOR OFFICE USE ONLY) tennessee board of regents Flexible benefits Plan Plan Year enrollment Form PleASe PriNt uSiNG A bAllPoiNt PeN. DATE EMPLOYED DEPT. CODE EFFECTIVE DATE PleASe mAKe A coPY For Your recordS. S T A T E U NI V E R S I T Y & C O M M U N I T Y C O L L E G E • S Y S T E M O F T E N N E S S E E MCML XXII TENNESSEBOARDOFREGENTS Enrollment Status: New Enrollment Re-enrollment E-MAIL ADDRESS Employee Signature Date Signed the teNNeSSee boArd oF reGeNtS reSerVeS the riGht to reduce SAlArY reductioN electioNS AS mAY be reQuired to meet FederAl reQuiremeNtS. ( ) PAYROLL FREQUENCY (Refer to list in your Reference Guide, available at medicAl eXPeNSe FleXible SPeNdiNG AccouNt Maximum allowable annual contribution is $2,500 per employee. Box #1 Total Plan Year Dollar Amount _________________ Box #2 Number of Regular Paychecks Expected ÷ ___________________ Box #3 Reduction Per Regular Paycheck = _________________ dePeNdeNt cAre FleXible SPeNdiNG AccouNt TAX FILING STATUS [PLEASE CHECK ONE]: o Married, filing separately [maximum - $2,500] o Married, filing jointly [maximum - $5,000] o Single, head of household [maximum - $5,000] Box #1 Total Plan Year Dollar Amount ________________ Box #2 Number of Regular Paychecks Expected ÷ ___________________ Box #3 Reduction Per Regular Paycheck = ________________

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Page 1: 2014 Enrollment Form - Tennessee State University

Important• Iunderstandthatthisisnotanapplicationforinsurance.Toenrollorchangemymedicalordentalinsurance,Imustcompletetheproperinsuranceforms.• Iherebyauthorizemyemployertoreducemygrosssalarybeforefederal,stateandsocialsecuritytaxesarecalculatedbythetotalamountofannualsalaryreductionindicatedabove.• IunderstandthecontributiontomySocialSecurityaccountwillbereduced,sincecontributionswillbebasedonmyincomeafterreduction.• I understand that any amount remaining in any Flexible Spending Account that is not used during the plan year will be forfeited since it cannot be carried forward to the next

plan year.• IunderstandthatthefundsinoneFSAaccountcannotbeusedtoreimburseexpensescoveredbyanotheraccount.• IunderstandthatexpensesforwhichIamreimbursedcannotbedeductedonmyincometaxreturns.• IunderstandthatthefundsintheFSAaccountcanonlybepaidouttoreimbursepaymentofeligibleexpensesactuallyincurredduringtheplanyear.• IunderstandthattheamountofsalarydeductionwillincludetheitemsspecifiedaboveandwillcontinueineffectunlessIterminateemploymentorfileanapprovedchangeinstatus,within90daysofa

qualifyingevent.• IunderstandandagreethatmyemployerandFringeBenefitsManagementCompany,aDivisionofWageWorks,willnotincuranyliabilityresultingfromeithermyparticipationinormyfailuretosignor

accuratelycompletethisEnrollmentForm.IfurtherunderstandthatifIelectnottoparticipateinsalaryreductionwithrespecttothebenefitslistedabove,Iherebyforegomyrighttoparticipateduringtheupcomingplanyear,unlessotherwiseprovidedbylaw.

• IunderstandthatImaybeaskedbytheIRStoprovidetheFEInumberofmydaycareprovider.• I certify that: 1) I will only use my FSA to pay for IRS-qualified expenses and only for my IRS-eligible dependents, 2) I will exhaust all other sources of reimbursement, including

those provided under my Employer’s plans before seeking reimbursement from my FSA, 3) I will not seek reimbursement through any other source, and 4) I will collect and maintain sufficient documentation to validate the foregoing.

FlexibleSpendingAccountsCompletetheworksheetsprovidedinyourReferenceGuidebeforedecidingontheamount(s)tobeenteredinthesectionsbelow.Ifyouhavequestions,consultyourReferenceGuide,orcallCustomerCareat1-800-342-8017.YoumayalsocontactCustomerCareatwww.myFBMC.com.InBox#1,indicatethetotaldollaramountyouelecttocontributeforthe PlanYear.InBox#2,indicatethenumberofregularpayrollchecksyouexpecttoreceiveduringthe

PlanYear(consultyourpayrollofficeifyouareunsureofhowmanychecksyouwillreceive).InBox#3,indicatethereductionamountperpayperiod.

()

CustomerCare1-800-342-80177a.m.-10p.m.

12 2624

WORKPHONE HOMEPHONE HOMEADDRESS[STREET] CITY STATE ZIP

LASTNAME FIRSTNAME M SOCIALSECURITYNUMBER

PAYCHECKEFF.DATE:(FOR OFFICE USE ONLY)

tennesseeboardofregentsFlexiblebenefitsPlan

PlanYearenrollmentForm

PleASePriNtuSiNGAbAllPoiNtPeN.

DATEEMPLOYED DEPT.CODE EFFECTIVEDATE

PleASemAKeAcoPYForYourrecordS.

STATEUNIVER

SITY&COMMUNITY

COLL EGE•

SYSTEM OF TENNESSE

EMCML XXII

TENNESSE BOARD OF REGENTS

EnrollmentStatus:

NewEnrollmentRe-enrollment

E-MAILADDRESS

EmployeeSignature DateSigned

theteNNeSSeeboArdoFreGeNtSreSerVeStheriGhttoreduceSAlArYreductioNelectioNSASmAYbereQuiredtomeetFederAlreQuiremeNtS.

()

PAYROLLFREQUENCY(RefertolistinyourReferenceGuide,

availableat

medicAleXPeNSeFleXibleSPeNdiNGAccouNt

Maximumallowableannualcontributionis$2,500peremployee.

Box#1Total PlanYearDollarAmount _________________

Box#2NumberofRegularPaychecksExpected ÷___________________

Box#3ReductionPerRegularPaycheck =_________________

dePeNdeNtcAreFleXibleSPeNdiNGAccouNt

TAXFILINGSTATUS [PLEASE CHECK ONE]:

o Married,filingseparately [maximum-$2,500]

oMarried,filingjointly [maximum-$5,000]

oSingle,headofhousehold[maximum-$5,000]

Box#1Total PlanYearDollarAmount ________________

Box#2NumberofRegularPaychecksExpected ÷___________________

Box#3ReductionPerRegularPaycheck =________________

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NEW ELECTIONS MUST BE FILED FOR THE 2014 PLAN YEAR
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